Nutrition Interventions for Children with Special Health Care Needs

Chapter 20 - Nutrition Interventions for Short Bowel Syndrome
Long-Term Nutritional Concerns in Short Bowel
Syndrome
Micronutrient Deficiencies
Once a child is on full enteral or oral feeds and parenteral nutrition has been
discontinued, adequacy of micronutrient absorption becomes a concern. This is
especially important when a significant portion of the ileum is missing. Ileal resection
can result in fat and fat-soluble vitamin malabsorption; it is frequently necessary to
give fat-soluble vitamins in a water-soluble form. These are available in individual
vitamin preparations or in multivitamin preparations (e.g., ADEK’s ® ), which contain
water and fat-soluble vitamins, all in a water-soluble form. Additionally, children with
ileal resection may need vitamin B12 injections every 1 to 3 months. It can take from
several months to several years for a vitamin B12 deficiency to develop; therefore,
long-term, regular monitoring of B12 status is necessary. Vitamin B12 is often given
routinely to prevent deficiency when the terminal ileum has been resected (4).
Minerals that may be malabsorbed include calcium (often due to vitamin D
malabsorption), iron, magnesium, and zinc. These nutrients need to be monitored
periodically, especially in the months just after parenteral nutrition is discontinued,
and whenever a patient develops a prolonged diarrheal illness or has bacterial
overgrowth (4).
Bacterial Overgrowth
Children with short bowel syndrome often have poor intestinal motility and dilated
segments of the small intestine. This, plus absence of the ileocecal valve, contributes
to the development of bacterial overgrowth (3). Bacterial overgrowth is present when
the bacteria in the small bowel exceed normal levels. Bacterial overgrowth results
in malabsorption by causing inflammation of the bowel wall and deconjugation of
bile acids. This results in rapid reabsorption of bile, leaving very little bile for fat
absorption. Symptoms include very foul smelling stools and flatus, bloating, cramps,
severe diarrhea, gastrointestinal blood loss, and accumulation of D-lactic acid in the
blood. Bacterial overgrowth can be diagnosed by breath hydrogen test either fasting
or after an oral glucose load, by aspiration and culture of small bowel contents or
by blood test for D-lactic acid. Bacterial overgrowth is treated with oral antibiotics.
In many cases it is necessary to give cyclic antibiotics for the first five days of every
month. For some patients continuous antibiotics are necessary; in these cases,
230 Nutrition Interventions for Children With Special Health Care Needs